All Information Is Strictly Confidential.

What would you like to get from your coaching sessions working with me?

What is you dream outcome. What is the thing or things that if you achieved would have you thinking hiring a coach was one of the best decisions you ever made?

In an ideal world, what would you really like to achieve in your life that you have maybe given up on or think is out of reach?

What would you say have been your 3 best accomplishments to date?

What is the hardest thing in your life you’ve had to overcome?

What stresses you out?

How much stress do you have in your life right now?

Preferred Phone Number:

Alternate Phone Number:

What is you preferred method of holding our sessions?

Phone:

Skype:

Google Hangouts:

E-Mail Address you want me to use to contact you:

Date Of Birth:

Do you have a partner, if so what is their name?

Do you have children, if so what are their names and ages?

Do you have a website, if so what is the URL?

Are you currently under the care of a medical doctor or mental health practitioner for specific non-routine issues? If yes, please give more details.

Are you taking any prescribed medication and if so, please list and explain what condition they have been prescribed for?

Do you smoke? If so, how many per day approximately?

Do you drink, if so how many drinks per day approximately?

Do you now, or have you ever used recreational drugs, if so what and when?

Is there any other information that you think I should be made aware of?

On a scale of 1 to 10 (1 being as bad as it could be and 10 being fully achieved/happy) grade each of the categories below as they are for you now. For example, if you are fully satisfied with the amount of time, energy, attention you are paying towards your savings put a 10 in the box next to savings.

Health:

Diet:

Fitness:

Fun:

Social:

Wealth/Savings:

Salary:

Career/Job:

Colleagues:

Friends:

Significant Other/Partner:

Family:

Giving Back/Charity:

Relaxation:

Meditation:

Peacefulness:

Spirituality:

Spirituality:

Coach Disclaimer of Liability: Client (“you”) hereby employs the Coach for the purpose of supporting you with respect to your self-awareness, vision and goals, and strategic plans, has experience in such matters and agrees to render such coaching services. Client understands that the Coach is not a psychologist, psychotherapist or mental health provider. Coaching does not include psychological counseling, psychoanalysis or behavioral therapy.